In 1896 a textbook of surgery had noted that operating on a heart is impossible. Muscles of the heart are always in motion, and its chambers are always churning blood. Heart is enclosed in a thick cover. We know this cover as pericardium. While, in 1893 an American surgeon Daniel Hale Williams had stitched a torn pericardium, this is not usually counted as a first cardiac surgery. Rather, credit for first successful cardiac surgery goes to a German surgeon Ludwig Rehn. In September of 1896, he had sutured a torn right heart chamber. His patient was a person with a stab wound, that had punctured his heart.
Six month after this successful surgery, Ludwig remarked “…..I trust that this case will not remain a curiosity, but rather, that the field of
cardiac surgery will be further investigated. Let me speak once
more my conviction that by means of the cardiorrhaphy, many
lives can be saved that were previously counted as lost“. With these words, Ludwig signalled the birth of Cardiac surgery.
A primer on anatomy of heart
Heart has four chambers, two thin-walled atria and two thick-walled ventricles. One pair of an atrium and a ventricle forms the right heart, and another left heart. Right heart pumps blood into the lungs, for it to gain oxygen. The oxygen rich blood comes to left heart, which pumps it to all over the body. Traditionally we depict right heart as blue, and left heart as red. One valve guards entry and another allows exit of blood from each of the ventricles.
Surgeries on the congenital heart
Some children are born with a defective heart. There may either be a hole or a conduit that abnormally connects right and left sided circulations. Early cardiac surgeries were correction of such defects. In 1938, Robert Gross closed an abnormal conduit (called PDA) which connects the right and left circulation. Robert Gross was a trainee surgeon, and chanced upon this operation, when his chief was away on a holiday.
Sometimes the defects are more complex that they disturb the flow of blood, and not allowing it to gain enough oxygen in the lungs. One such defect where children are blue (or cyanosed) early in life, is Tetralogy of Fallot’s or TOF. In 1943 Blalock and Tussing performed a arterial switch operation in a child with TOF. About nine years later in 1952 John Louis in Minnesota performed the first successful closure of an abnormal hole connecting the two atria. All these surgeries are done on small children, with small hearts and tiny vessels.
Correcting the faulty valves
Mitral valve is located between the left atrium and ventricle. It becomes narrow or stenosed in rheumatic heart diseases. In 1925, a British Surgeon Henry Souttar, opened the heart and inserted his little finger inside the left atrium, to open a blocked mitral valve. While this surgery was successful, it was considered as risky. Souttar was never allowed to operate again. It was only in 1948, that surgeons in England and America would operate on the blocked mitral valve. Incidentally they used the same technique as Souttar. However, till 1950s, cardiac surgery was still in its infancy. Most surgeries were done either in the vessels around the heart, or by making small openings.
Two advances in 1950s, made more complex heart surgeries possible. First was to bypass the blood from the heart, when surgery was in progress. Initially John Gibbon and later Walter Lillehie pioneered how create such a bypass. Blood was moved out of the body by artificial conduits, oxygenated and returned back. Second development was ability to cool the heart, so that its stops beating during the surgery. This technique is called cardioplegia. Together bypass and cardioplegia opened the doors for open heart surgeries.
Coronary artery bypass
Today, bypassing the blocked coronary arteries is the commonest cardiac surgery. No such surgery was ever performed before 1960, as there was no way to visualise coronary arteries. In 1958, Mason Stones performed the first coronary angiography in Cleveland clinic in United States. This was a chance discovery, and Mason followed up with more planned angiography later. Thus, in 1960s world of correcting blocked coronary arteries was open for the surgeons. First coronary artery bypass surgeries were performed by Robert Goetz in New York (1960) , and thereafter by Micheal Debakey in Houston (1964).
Rene Favaloro was an Argentinian surgeon at the Cleveland Clinic. He pioneered successful use of saphenous vein (a vein in the leg) to be used as a conduit to bypass blocked coronary arteries. He performed his first bypass in 1967, and by 1970 he had done more than a thousand bypass surgeries. Thus a popular technique of coronary artery bypass grafting (or CABG) was born.
Rene meets a tragic end
After his success at Cleveland clinic, Rene Favaloro returned to Argentina in 1971. He established cardiac surgery training center in Argentina, and a Favaloro foundation. Over next three decades, he trained countless of cardiac surgeons across Latin America. However by the year 2000, his foundation was in a huge debt. Rene was frustrated, as he was not able to find any financial support. On July 29, 2000, at age 77, Favaloro fatally shot himself in the chest. In one of his last letters, which was opened only after his death, he expressed his financial difficulties. This letter, addressed to the then president of Argentina, had words that “I have become a beggar in my own country”.
Christiaan Bernard and the first heart transplant
After these early developments, cardiac surgery saw more advances. Notable amongst these is the heart transplant. Christiaan Barnard was a surgeon, who received his medical training in South Africa. In 1955 he went to Minnesota to train under Walt Lillehei, a renowned cardiac surgeon. He retuned back in 1958, and was appointed as head of Cardiothoracic surgery in Cape-town.
In 1964, first heart transplant was done in Mississippi, United States was unsuccessful. In this surgery a Chimpanzee heart, was transplanted to a human. Many animal to animal heart-transplant experiments were done in animal laboratories till then. The technique worked, but was never tried in a human.
Barnard performed the world’s first human-to-human heart transplant operation in the early morning hours of Sunday 3 December 1967. A young woman Denis Darvall was the donor. Doctors had declared her as brain dead a day earlier. Louis Washkansky, a 54 year old grocer was the recipient. Overnight Christiaan was a celebrity. There are no actual photographs of the surgery, as none were clicked.
After initial success, The transplanted heart lasted 18 days. Mr Washkansky developed lung infection, which doctors initially mistook as inflammation. Baarnard’s second transplant in 1968 lasted 19 months, third lasted 20 months and the fifth one in 1971, for 23 years. (Read his incredible story here)
Cardiac surgery meets intervention cardiology
Another advance in cardiac surgery is development of prosthetic devices. We invented first artificial valve (ball and cage) in 1952. Then came tilted discs in 1969 and bileaflet valves we use today in 1979. List of such prosthetic cardiac devices is ever growing.
However, by 1980s intervention cardiology started growing in stature. These are a set of techniques, where we can reach the heart, through thin canulas that can be inserted through arteries or veins. First coronary stents were implanted in the year 1986. By the year 2000, we had developed advanced drug eluting stents. This has led to less and less need for coronary bypass grafts today. In addition to stents, we have also developed pacemakers and implantable defibrillators.
Many diseases that were previously treated by surgery alone, became a domain of interventional cardiology. The list is growing now with more devices that can repair valvular lesions. There is a growing concern, that cardiac surgery will eventually give way to advancements in percutaneous interventions. As we live through the future, we owe all the respect and gratitude to bold cardiac surgeons who over the years have dared to perform the unthinkable.
interesting
Nice Article sir